Okay. Good morning, everyone. Welcome to our session today, an ICU without nurses. Whose problem is it? We're going to hopefully have an invigorating panel discussion and then open it up for some question and answer. I'm Dorina Drizzo-Harris, very happy to be president of CHEST Hawaii this year, and thank you all for coming this far for our annual meeting. So we all know that the health of the nurse work environment has shown lots of issues lately. Both patient and nurse outcomes and physicians play a key role in nurse retention. Our ICUs cannot function without nurses. Fewer nurses decreases care, quality, and patient safety. And research shows that nurses' intent to leave has increased significantly since 2018 and even more after COVID. The CCSC, which is the Critical Care Society's collaborative, is a combination of ATS, CHEST, the American Association of Critical Care Nurses, and the Society of Critical Care Medicine, SCCM. And we've been getting together to think about ways to help improve this. And this is one of the ways to discuss it, to highlight the problems. There was a National Work Environment 2021 study that was published in 2022 in Critical Care Nurse, and I encourage you to look at that. The report really goes in detail into all the aspects, and you'll hear some of that. So today I would like to introduce our panel first. We have several speakers today. The first being Dr. Teresa Davis, and Terry is from the American Association of Critical Care Nurses. And then we have Dr. Jill Guttermsen, and she is our panelist representing the American Thoracic Society. Next we have Dr. Lauren Source, who is our representative from the Society of Critical Care Medicine. And last but not least, we have Dr. Chris Carroll, who's chair of our Critical Care Network, a pediatric intensivist, and he is our representative from CHEST. So at this point, I would like to give each of our panelists five minutes to introduce themselves, and they're each going to talk on a little different aspect of this. Terry's going to go first, and she's going to give us some of the background. Well, first of all, thanks for being here. We're so glad that you're here. And I know that someone was telling me how the title struck them, the ICU without nurses. Whose problem is it? It's all of our problems, of course. I'm Teresa Davis, also known as Terry. I'm the president of AACN. I'm very proud to be here. I'm from Inova Health System at Falls Church, Virginia. Just a little bit about the objectives. Really, we're looking at... I'm going to go through the standards of the healthy work environment, and also talk about some ways to create a sustaining way to create a healthy work environment, and also some exciting things that AACN is doing this year to really bring this forward. These are the six standards. Skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership. And if all of these standards are implemented within your unit, or even just one of these standards, we have seen improvements in the work environment of the nurse. So this really is the article that we were talking about, the national... the article that came out in 2021. It's really a status report. AACN has done this survey five times, and in 2021, they purposely did it a little early because we were in the middle of COVID, and they wanted to see where we were with nursing. And what we saw was there was a decline from 2018 to 2021 in all of the ratings in the healthy work environment scale. The largest decline was in staffing. So just some results. For decades, we knew there was a correlation between the healthy work environment, the health of the work environment, and the healthy work environment standards. So in this survey, we had 9,862 nurses that filled out the survey, but of those nurses, 13,335 were actively practicing as an RN, so they were appropriate in the survey. So 67% of participants said they plan to leave their current position within the next three years. That is really a serious call to action for us to know that we have a significant problem. The top responses to influence nurses to stay were around salary and benefits, better staffing, and respect from administration. And then also just remembering that the nurse psychological health and well-being is very strongly associated with healthy work environments. A few more facts. 56% of our RNs who felt valued and they were committed partners in decision making, policy making, and evaluating clinical care said they had no plans to leave their organizations in the next year, in the next three years. 55% of RNs that implemented HWE were very satisfied with being an RN compared with only 34% of those working in units that had not implemented healthy work environment. And then 26% of the participants working in units that implemented the standards intend to leave their position in the next 12 months compared with 52% of those working in units that did not implement the standards. So what are we doing about this? We've done a lot of work at the American Association of Critical Care Nurses along with partners, the American Nurses Association, the American Organization of Nurse Leaders, Finance, and the IHI, did Partners for Nurse Staffing. And they were really looking for collaborative solutions. And that led to a think tank which had six priorities, the healthy work environment, stress injury, a flexible work schedule, DEI, innovative care delivery models, and total compensation. From that work then came the National Nurse Staffing Task Force, which created a national dialogue and included direct care nurses. Many more folks joined that group. Which that group created five imperatives. Again, the healthy work environment, innovative models for care delivery, establishing those staffing standards, improving regulatory efficiency, and valuing the unique contributions of nursing. One of the big stances for the American Association of Critical Care Nurses was to allow nurses and leaders and others to seek to implement the recommendations. And that it will be most effective, whatever will be most effective in their environments. Another thing that we're very, very excited about is this two-pronged approach, the CSI Implementation Program. They're going to blend education and experiential learning with unit-based leadership in the innovation programs. And there's seven regional cohorts with 10 to 15 unit-based teams per cohort. And that work has begun already. It started in October. And then the second initiative that's coming out in 2024 is the National Collaborative. So it'll be education, mentorship, and it will be across a national network of 135 units in 45 hospitals. And they will use implementation science to guide those hospital leaders to engage with their teams and create sustainable changes to create a healthy work environment. So that is my part. And thank you for, don't forget to survey, to fill out the survey. Our next speaker is going to be Dr. Guttermsen. And she is dean of the, correct, the College of Nursing. So we really have this very esteemed colleagues today giving us their experience. And she is our ATS representative. She's going to talk a little bit about the story of nursing during the pandemic and gaps with onboarding and training of our new nurses. Jill? Hi, everyone. For this first bit, I'm going to focus on a survey that we did nationally in late 2020. I also want to say I am a critical care nurse researcher. And my, very proudly, my practice has all been as a critical care staff nurse. So in 2020, late 2020, a group of us really felt that we were worried we were going to lose the stories of the pandemic that were coming out from nurses in the ICU. So we did a national survey. There's been a few publications out because they answered about 400 in the middle of a pandemic chose to answer a survey and give us a lot of detailed information. I'll share some of that. And it's going to mirror a lot of what you've heard about healthcare workers and other areas and other parts of the country and in the world. The risk for PTSD, the percentage was higher than that we see in recent veterans or traumatic injury survivors. In our sample, a third reported severe or moderate anxiety. 45% reported symptoms that were moderate to severe depression. There are moderate levels of moral distress and burnout, much higher, as you can imagine, that was seen prior to the pandemic in similar samples. But what I want to take a little bit of time is share in their own words. It was really compelling to read their narratives and their experiences. And I'll say reading those and doing the content analysis of that was some of the hardest work my team had done. And we had to spend a lot of time talking it through. So if you'll indulge me, just a few quotes from the nurses themselves. Many of them did mention team was everything. If their team came together, it made a huge difference in how they perceived their work and how they perceived being valued by the organization. But there was a counter narrative that came up from more than a few nurses that really was the opposite of teamwork. It was undermining the healthcare team dynamics. We were not all in this together, said one nurse. We are at the bedside while physicians are writing notes stating to limit the exposure to COVID-19, this assessment was conducted from outside of the room. And there are nurses that will tell you stories during the pandemic where health, no one else went in the room other than the nurse. And the way that they describe that is being led to slaughter. It's really a compelling and profound narrative. And that may not be in your ICU, but that is some of the, what we're being told. Lack of nurses, you all probably saw some of that. Lack of nurses due to critical care nurses leaving. This summer we had six critical care nurses covering for 25 beds while we were all trying to train another nurse. They speak about in their amazing, the way that they describe what this was like for them is, I've been a nurse for 30 years and I've never seen anything like this in my life. And I never thought that I would. A direct quote, it was the most disturbing physically, emotionally, and mentally exhausting experience I have ever had in my life. Words cannot describe the exhaustion and the fear and the frustration. And I think a thing that had our team like most concerned was the number of nurses that said, it's not going to be over. Like, I don't know how I'll recover. I don't know how I'll get back. I don't know how I'll begin to love nursing again. I'll just read one quote to that. Our unit has been upended and our workflow has changed entirely. Things will truly never go back to the way they were in our hospital. I know I will never be the same person or nurse. I really thank you all for being here. We all shared a common trauma and I think we can find solutions together as the team, because I have in my career worked the most amazing teams in ICU across all disciplines. And I think us pulling together is going to make a huge difference. So thank you. Thank you very much, Jill. Our next speaker is going to be Dr. Lauren Soares. She's president elect of SCCM and she's going to talk a little bit about synergy of negativity. Yeah, so thank you for setting up my talk by landing on that negative statement. That wasn't planned, but it worked out well. So as we were planning, first of all, how many nurses in this audience? Okay. So great. Physicians. Okay. Non-physicians and non-nurses. Great. What professional group do you represent? You're a PA. Okay. And you? Okay, great. So this is, you know, all of what we're talking about, we can't do without any of the professions that are sitting in this room, right? It's not just about nurses. It's about everybody. But we're focusing today on nurses. And when we were planning for this session, I was telling a story about something that had recently happened in our ICU. So you're aware the ICU that I work in is a free-standing children's hospital. And when COVID hit, we were prepared to start taking adult patients from our, what I'll call sister hospital, Northwestern University Medicine. And that really never happened. Instead, we sent physicians over to facilitate the care of their patients in their ICUs. And instead, what happened by being in a city that had lockdown, we essentially cured pediatric infectious diseases. And while it's great that we, you know, kept kids home and kept them from getting sick, the impact on the hospital was well beyond what anybody could have ever imagined. And other free-standing children's hospitals are still suffering the impact, the financial hit that that created. The massive loss of employees, even though they cut salaries for a period of time, it took a while for kids to start coming back once the lockdowns were lifted. And then when they did start coming back, they started coming back in what we called in pediatrics, the triple-demic. We were getting killed by three viruses and kids were coming in incredibly sick all to a unit that was not well-staffed and multiple units that were not well-staffed, not just mine. So many units then hire travel nurses. So there was a lot of travel nursing during the pandemic. There were exorbitant amounts of money paid to travel nurses. And that funding started coming down as hospitals realized they can't continue financially to do that. But many hospitals still need travel nurses because they don't have enough nurses. So as I was clinically on service one day, I was working with a patient who had a travel nurse who has traveled at many top 10 children's hospitals. And we were talking about supplementing the patient's potassium. And so I ordered a K. bolus enterally. And for about the next hour, I was texted multiple times about how to give some enteral potassium. And it dawned on me, not just in that situation, but in others that I had experienced that even with our own staff nurses that are coming out in droves from education that was not what we would have normally done in the pandemic, they're not prepared to provide care at the bedside in ICU in the way nurses have been prepared in the past. And so what I discovered is they're not capable of doing some critical thinking things. And we need that in the ICU. You have to be able to critically think about what's happening with the patient. And it sort of became this sort of synergy of negativity where people became negative about the care that's being delivered because of the inability to be efficient with the care by different members of the team. And this synergy of negativity, everybody knows what synergy is. One plus one is three. That's the easy example of synergy, right? But in synergy of negativity, it's one plus one is like minus three. And everybody begins to sort of get sucked into the negative and then become a place where there is no psychological safety, which is critical to have a very effective team. I have a lot more to say, but that's it. Well, I wanted to also give, okay, two more minutes. I wanted to also give some information for those of you who saw the perspectives written in JAMA in the October 4th article by Dr. Saran talked about some of overworking and understaffing the burden in nursing. And in that paper, they talked about the National Council of State Boards of Nursing did a survey recently. They surveyed 335,000 nurses, LVNs, LPNs, and greater than 25% of them said they intended to leave the profession by 2027. And in a sub-analysis, they discovered that 100,000 of them had already left the profession. And then in April, the NC NSB also predicted or projected a loss of 800,000 more nurses within the next four years. So for those of you who follow workforce research, Dr. Linda Aiken, who's at UPenn is a premier researcher in nursing workforce. And she has quoted in the paper and says, it's really not a nursing shortage problem. So we're putting out almost 200,000 nurses per year from schools of nursing really as a deployment problem. So nurses are leaving high stress areas and going to other areas of the hospital. Okay, so you work in critical care as a critical care nurse. Where do all the ICU nurses go when they leave the ICU? To the clinic, right? To the PACU, right? One call. Yeah, right. Exactly. You know, to scheduling, to facilitating appointments, things like that. So that's what's happening. So the reason this is happening is because of understaffing and burnout. So I'll leave it there. Leave it at that. We can talk more. We'll get back to some more discussion on that. Thank you, Lauren. Okay, Chris. Chris, you're going to tell us the physician's perspective. Yes. Thank you for inviting me. I'll be the physician target of this because I do think physicians have a lot to do with creating healthy work environments. A little bit about me. I'm a pediatric intensivist like Lauren, trained where Lauren trained. And recently moved from Connecticut to Florida. In Connecticut, where I worked in a freestanding children's hospital, we had the same challenges. When I left six months ago in Connecticut, we had 16 FTEs open for open. 16, one six. And we could train six nurses every six months. So there's no way of getting out of that hole. You just are never going to get out of that hole. You're required to hire travelers, which adversely impacts the quality of care delivered as well as the financial impact of the hospital. Where I moved in Florida, we currently have no open positions. We're fully staffed, which was shocking to me when I interviewed, and it still remains shocking to me this day, whenever I check, it's that we still have no open positions, which is shocking in an ICU. So what's the difference? I really think the difference has to do with the healthy work environment. The degree of psychological safety at my new institution is much higher, or lower, depending on how you do the scale, much higher. People feel more safe at my new institution to talk about things. They feel more appreciated, more empowered. There's more collaboration among the nurses, as well as among the physicians and the subspecialists. They feel more supported as a result of that, and it's a palpable difference. So I think there are lots of problems out there, yes, that we've arranged, but I think they are addressable as well, too. So anyway, I'll turn this over. Okay, thank you very much, Chris. So I think we've heard a lot about the problem, where things stand, and so now we're at a place of we need to find what solutions have to be accomplished, and how we do that collaboratively together. We had a great Women in Chest Medicine luncheon yesterday, which highlighted on the panel a physician, two physicians, a respiratory therapist, and a critical care nurse, and I think it was great that we started talking about some of the issues of collaborating, how the respect that needs to be there between the trainees, the nurses, the physicians, the allied health members on the team, whomever, and we forget about that a lot of the time. Everybody's under a lot of stress, especially post-COVID, and I think my feeling is there's not enough respect there. If we really start to think of people as colleagues, and not just somebody who's telling us additional things we have to do for the patient, or upset with us because we're maybe bringing up a second idea or opinion, and instead say, okay, well, that's a good way to think about things. Maybe we should discuss this. I know that, you know, in our ICU, we're often always struggling with those positions of who's in power, who's in charge, instead of really looking at it as one big team all working together with the patient. So, I'm gonna ask the panel to perhaps suggest some of their thoughts on what some of the potential solutions could be. So, Terri, why don't you just focus a little bit on how do we make the healthy work environment truly a healthy work environment? Thank you. Well, I will tell you, I've been a nurse for 37 years. I've been at the same organization for 37 years, and we have great interprofessional relationships. So, I'm trauma neuro ICU by background, and one of my favorite things to do is to participate in groups that have physicians, nurses, respiratory therapists, everybody, you know, multidisciplinary, coming up with plans and a future for how we care for our patients. It can be very rewarding, and the younger generation that's come in really likes to be a part of projects and be a part of design and creating things. If we don't create an environment where they're able to do that kind of work, they're not staying. They're not like me who stayed for all those years. They think differently, and if they don't like the environment, they're going somewhere else. There is a channel of nurses coming in who want to advance their career by doing nurse practitioner, advanced nursing, all of that, and I think that should be celebrated, but we have to have a model in place that then reinforces and brings in new nurses, and we also have to encourage the nurses who want to stay by the bedside, give them a reason to stay, and those interprofessional teams and how we talk to each other are what makes the difference. If you've never heard of a theory called relational coordination, it talks about shared knowledge, shared goals, and mutual respect. If you communicate in that way with your teams, it will enhance quality and safety, and it will make a huge difference in the work, and people will stay. I was just reading on the way here and always about interprofessional teams and interprofessional education, and I think one of my favorite things is interprofessional is not all the people being in the room together. It's actually valuing experience. It's trusting each other. It's asking for differing opinions. It's asking for different perspectives, and doing that in really every interaction, and I think that's where the best of it comes. When I talk to nurses that are entering into the workforce, I actually tell them your population is the least of your concerns in your first three years. Find a culture where they're gonna support you and onboard you and mentor you, and that's gonna come from every member of the healthcare team. That should be the job that you take, and it really is everything for retention. Nurses will stay. They will stay a really long time if they feel really valued on that unit, and that's a work of all of us, making sure we're elevating voices. So I wanted to point out that's not only true for critical care nurses. That's pretty much true for anybody you're recruiting to your institution. We used to have a very high turnover rate for NPs on the ambulatory side, and what we really instituted was that team approach, that huddle, weekly meetings with the whole team, including nutrition, respiratory therapy, everybody feeling like they are all together taking care of the patient and empowering them in what they do well, and everybody's good in something else, and respecting them, and I think we've had NPs now, six, seven, going on eight years, and very, very happy in the environment, but we had to make that conscious effort to do that. It does take more time, no question about it, but then it pays off in the end, so I think something you can bring back to your own institutions, those of you who work in the ICU, is start thinking about is this happening in your ICU? If it isn't, talk to your medical ICU director. Maybe you have to go above that person to your administration, figure out ways that some of this can start to organically be a part of the ICU. I know a lot of places are trying to do it, but how well you do it is also a question. It's not just getting people in the room. If you don't respect them after they're in the room, it's a waste of time. All right, I'm gonna ask, Jill, why don't you talk a little bit about the training? You mentioned it takes so long to train individuals to be ready to be in these environments. How can we shorten that? How can we do it more efficiently? Yeah, a couple of interesting things that came out of the pandemic when we were working with our nursing students. We switched to virtual clinicals. Skills, talking to family, none of that can happen virtually. Strangely, and maybe not, what we heard from our clinical instructors when we went back out onto the units across different types of specialties, their clinical judgment had improved. Their ability to know what cues they were supposed to be paying attention to and what might come next and what, that actually had gotten better by working through clinical simulation. What had gotten harder was the coordinating the 8,000 things that a nurse does in their day. So if you've never heard of compression complexity, that's where we're really pushing at our college to how do we help nurses navigate the fact that they are working with eight different types of tech, they are working with PT and OT and RT and the medical team, and in the ICU, possibly five different medical teams, and they are coordinating all of that care. How do you simulate that? Because that doesn't happen in training. And so that's where we're really pushing forward is how do we help them understand that complexity? I also would like to just say a word about some possible partnerships that we've had great success for retention. If you don't have these at this hospital and you have a good relationship with your nurse leaders, we do a lot of dedicated units where our nursing students stay on the same unit throughout their training, and then they hire onto that unit, and we're seeing much better retention and satisfaction, and they come out much more ready for practice because they know the system, they know the hospital. So happy to talk to anybody who wants to think more about that. And then I just want to say, if I might, a word about what we all owe each other in training. If you happen to be an ICU physician, you don't have to self-disclose, I'll just ask you to reflect, and you are a new resident or a new fellow in ICU, was it possible that super experienced nurses ever helped you through your shift? And I think it's the same thing, right? Like we're all moving toward the same target. So when you have that nurse that's struggling and asking a lot of questions, be happy that they feel ready to come to you and ask you that question, right? The worst case scenario is that they don't ask. And so I just think that that actually was the joy, it's why I always chose teaching hospitals to work in. I loved that we were all helping each other learn together from our different lenses. So I just wanted to add that to the kind of the story that was told earlier. Thank you. Thanks, Jill. Lauren, I know you're supposed to give us a little bit insight on team solutions. I thought also, I was thinking, I know there were a big piece of the survey that was published discussed harassment that the nurses experienced, not just from their physician colleagues, but from everyone I've reviewed it today, patients, family members, trainees, other nurses, and if you wanted to reflect on that a little bit too. Sure. So different than the adult world, the pediatric world has always had what we call family center rounds. And families have always been an integral part of everything that we do because we can't take care of children without their legal guardians or their parents with them. And things really got amped up with families who were suffering tremendously. And because things got ramped up with families, things got ramped up within teams, increasing sort of this harassment. And I'll reflect back on the story that Dr. Tatum told yesterday at the Women in Medicine luncheon where she talked about the first time she was in the ICU as a resident, she had a nurse basically tell her that, mm-mm, she ain't working with her, the end. She don't like people like her, whatever that meant. And as a nurse, I sat there and I was embarrassed as a member of this amazing profession. And I also recognized that nurses did that to me when I started in nursing as well. And I'll never forget being looked up and down by this one incredibly experienced nurse and feeling like, I don't know that I'm gonna actually make it here. And I'm still there 35 years later. But the harassment that goes on within nursing is not a secret, it's well-known. And this is what I will say about it with regards to teams. And something Dr. Betancourt said yesterday about not fitting within a team. So I firmly believe that you must align your mission, vision and values as a professional with the mission, vision and values of the institution where you work. If you don't, you're temporary. And it's fine if you know that, but then you have to be your best self while you're temporary. If you align, then you're fully in, you're dedicated. And when things go awry, you then also have the responsibility to figure out how to get things back in line. And so when things like this go on, it really is going to the leadership and saying, all right, these are the things that I'm seeing in an incredibly calm, data-driven way to limit the synergy of negativity. To have a discussion about, all right, these are the things that are happening, these are the outcomes that we're seeing. And I think we need to meet together as a team to figure out how we're going to do this work. And if you don't have psychological safety in your unit, that's incredibly hard to do. And finding somebody at your institution that you can have that conversation with in a psychologically safe way who can then bring that concern up through the leadership. There was an interesting paper that was published just recently by McClainey in Healthcare Management Forum where they really wanted to put together a framework of interprofessional collaboration. And I would encourage you to seek out this paper because what they did was they put together a grassroots team, like this is what they needed to do. And instead of being like a top-down directive, it was a bottom-up directive. And every step of the way in their iterative process to build this framework, they engaged people from all levels at the hospital to say, all right, this is now our framework. And their framework has four domains, six competencies, and 19 behaviors that they're rolling out in this institution. And that is something that is taking the bull by the horns and saying, all right, we need to be better at what we do. And when we're better at what we do as teams, as collaborative teams in clinical care, we have better outcomes. So I think it is initially, to sort of summarize, it's a recognition that it's happening. It's accepting any accountability for your individual contributions to what's going on. And then taking that and making a decision of whether or not what your work is still aligning with what the work of the place is, and then doing something about it. Okay, thank you very much, Lauren. All right, Chris. You have to tell us what the physicians need to do differently. I think that we've talked about psychological safety and team building. I think just to build a little bit on what Dr. Source said, that there are institutions that are not interested in changing. And so it is important that, although living to the values of your institution is important, there are many institutions that have values that are not interested in living up to them. They're just words on a paper, and the values mean nothing unless you're actually living up to them. So I do think we have to acknowledge that, and that there are plenty of leaders and institutions who are not willing to do this, and would rather just pay the extra money to hire the travelers than improve the culture of the institution. What's that expression that culture trumps? You guys are? Culture eats data for breakfast? Anybody know that expression? Something like that? Yeah, there we go. Someone's smarter than me. Culture trumps strategy, yes. So changing culture is much harder, and a lot of what we're talking about is changing the culture. And physicians have a big role in that. A physician on rounds in the ICU sets the tone for that unit just by how they, from the minute they walk into the unit until the moment they leave, just their presence, be it hostile or pleasant, is going to dramatically change the culture of that unit. And I've seen that. I mean, all of us who work in ICUs have seen that. We can see, like, oh, so-and-so is on, it's gonna be a bad day. Oh, so-and-so's on, the day's gonna go great. In fact, I walk into the ICU, every time I walk into the ICU, I say, today's gonna be a great day. No matter what, it's always gonna be a great day. Because if it's not, then, you know, I think that physicians have a lot to do with building the culture. And, you know, I don't have a magic way to fix culture in institutions where it's broken, but I do think that what we're doing here and talking about it is an important step in that process. Can I, yeah. Absolutely, continue. So in preparing a talk on teams and collaboration, I came across this paper that was published in 2014, and they interviewed all these team members. And it was fascinating to find that the more interprofessionally diverse a team was, and the more each member of that team held tightly to their professional identity, the less they were a good team. And it was really interesting. And I think that the nature of the teams that we're a part of, it's not that we have to give up our professional identity in order for our teams to be effective, but rather we have to understand what our contribution is to that team and how we interact with that team to make it that positive culture. Because you're always there. So what you're saying is if you're always there, just representing the nurses or the doctors rather than the institution, the one team approach, then it's interesting. Or rather than the team for the patient. Rather than the team for the patient. That's right. We're all working towards one goal. That's right. We're setting each other up pretty well here. I was just about to say interprofessional education, where you are doing things and solving clinical problems are great and amazing, and we should keep doing that. Interprofessional education, where you actually start talking about the training and the roles and the values and the perspectives from the different lenses can really, really help so that you can then pull yourself out of being nursing does this and nursing can and nursing can't. Rather, and really focus on what are the best goals and the way to get this done for the patient. And so the conversations happening during training I think are vitally important that they carry that with them and it can't be a checkbox, IPE was done so I can get accredited. It has to be like really substantive IPE. You've given me a great idea. We have our first five minutes program for the outpatient setting. Maybe we should set one up where, I mean, it's all about communication. And as you said, it's that first, whatever you say to the team when you're rounding, right? How you set the tone, how you address the other people on the team. Maybe this is where we next go, first five minutes for our ICU team and what's important and how you should, different scenarios, how you deal with them. Well, I like what you're suggesting there because you're using the first five minutes not to just for your interaction with the patients but your interaction with the team. Very important. I mean, we've all been on ICU rounds. You walk into the unit, there are 16 other people standing there. Right, and you're focused on most of the time, I mean, I think most physicians are concerned about the complex cases, figuring out how to treat the patient. Sometimes they forget about all the other aspects that go into that when you're very focused and very busy. And I think stepping back and thinking about those things and maybe having some formal training might be something that we can think about. Thank you very much on that wonderful note. We're gonna thank our unbelievable panel. Thank you so much for highlighting all of the issues. Okay, bring some of it back home to your own institution and enjoy the last day and a half of CHEST.

nurse staffing

intensive care units

patient care

healthy work environment

interprofessional collaboration

COVID-19 pandemic

nurse retention

positive work culture